Management Of Displaced Proximal Humeral Fractures

Article ID: WMC001232 2046-1690

Management Of Displaced Proximal HumeralFracturesCorresponding Author:Dr. Soumya Chakraborty,Junior resident, Orthopedics, PGIMER, Department of of orthopedics,PGIMER, 160012 - India

Submitting Author:Dr. Soumya Chakraborty,Junior resident, Orthopedics, PGIMER, Department of of orthopedics,PGIMER, 160012 - India

Article ID: WMC001232

Article Type: Review articles

Submitted on:28-Nov-2010, 04:49:57 AM GMT Published on: 29-Nov-2010, 08:28:09 PM GMT

Article URL: http://www.webmedcentral.com/article_view/1232

Subject Categories:TRAUMA

Keywords:Proximal humerus, AO/ASIF, Neer,Locking plate. Hemiarthroplasty

How to cite the article:Aggarwal S , Chakraborty S , Kumar V , Bali K . Management Of Displaced ProximalHumeral Fractures . WebmedCentral TRAUMA 2010;1(11):WMC001232

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Management Of Displaced Proximal HumeralFracturesAuthor(s): Aggarwal S , Chakraborty S , Kumar V , Bali K

Abstract

Treatment decision of displaced proximal humeralfractures is based on bone quality, fracture pattern,degree of displacement and patient profile. TheAO/ASIF fracture classification helps in guidingtreatment. Nonsurgical treatment consists of slingimmobilisation. Surgical options include closedreduction and percutaneous pinning, open reductionand internal fixation with either conventional or lockingplate and hemiarthroplasty. Planning should be doneon an individual basis depending on patient andfracture characteristics.

Introduction

Proximal humeral fractures with a dual age distributionoccurs either in young people following high energytrauma or in those older than 50 years with lowvelocity injuries like simple fall [1,2]. Three fourths ofthe fractures occur in older individuals with anoccurrence three times more often in women than inmen [1,3]. Most of the proximal humeral fractures arenon displaced or minimally displaced and stable.These can be treated non operatively successfully withearly rehabilitation. But severely displaced andcomminuted fractures warrant surgical managementfor optimum shoulder function. Surgeons should befamiliar with the different treatment options available.Treatment of this complicated fracture is guided bybone quality, fracture pattern, degree of comminutionas well as patient factors such as age and activity level.Ultimate goal should be minimum shoulder pain andmaximum range of motion. Surgical options includeclosed reduction and percutaneus pinning(CRPP),transosseous suture fixation(TOSF), open reductionand internal fixation with either conventional or lockingplate and hemiarthroplasty. Fracture must beevaluated on individual basis and treatment tailoredaccordingly.

Anatomy

The dynamics of this highly mobile joint are theconsequence of its particular bony anatomy and of its

soft tissue envelope. The skeletal anatomy of theglenohumeral joint comprises two retrovertednon-constrained articular surfaces. Mallon et al [4]have made measurements of the glenoid and found amean transverse diameter of 24 ± 3.3 mm, a meansuperoinferior diameter of 35 ± 4.1 mm, a meanposterior version of 2.0 ± 4.2° (-7 to -12) and a meanradius of curvature of 36.6 ± 7.4 mm (24 to 50). Theproximal humerus has a cartilaginous surface which istilted 45° upwards and about 20° posteriorly withreference to the distal intercondylar line [5]. Usingradiological techniques, Cyprien et al [6] andDebevoise, Hyatt and Townsend [7] measuredhumeral retroversion. The former found a mean valueof 26.9 ± 12.22° on the right and 21.2 ± 11.02° on theleft. The latter group determined a mean value of 61.6°(47 to 65) on the right and 60.8° (47 to 85) on the left.The quasispherical surface of the humeral headoccupies approximately one-third of a sphere with anangular value ranging between 120° and 150°. Theradius of curvature in the axial plane is 22 ± 1.7 mmand the radius of curvature in the coronal plane is 24 ±2.6 mm [8].The vascular anatomy of the humeral head plays amajor role in the outcome of trauma. A devascularisedhead will collapse and become incongruent, with thedevelopment of secondary arthritis. The arteriaarcuata circulates within the humeral head andreceives its blood supply from four major sources: themetaphyseal artery, the branch of the anteriorcircumflex artery in the bicipital groove, arteries fromthe rotator cuff and the medial branch of the posteriorcircumflex artery [9, 10, 11 ]. Because of this arterialpattern a fracture through the anatomical neck willlead to complete devascularisation of the fragment ofthe head which carries the articular surface. Thepower link between the scapula and the humerus isensured by the glenohumeral muscle groups whichdirectly cross the joint, namely the teres major, thedeltoid with its three functionally independent anterior,middle and posterior segments, and the rotator cuff.The last consists of the musculo tendinous units ofsubscapularis, supraspinatus, infraspinatus, and teresminor [12]. The biceps and its tendinous long headmay also be considered as part of the rotator cuff. Thebiceps tendon is a valuable surgical landmarkseparating the lesser from the greater tuberosity andtherefore is of help in identifying the various fragments



with their attached cuff tendons when dealing with adisplaced fracture of the proximal humerus. Thestructures medial to the biceps tendon aresubscapularis and the lesser tuberosity while thoselateral to it are part of the greater tuberosity andattached tendons of supraspinatus and infraspinatus[13]. The axillary nerve is at risk in these fractures [14].It supplies the deltoid and teres minor muscles andshould be tested for motor and sensory function on thelateral aspect of the shoulder before any attempt atmanipulation for fracture of the humeral head. Atoperation it should be visualised or at least palpated,since it lies anterior to subscapularis before plungingbeneath the tendon of subscapularis and theglenohumeral capsule into the quadrilateral space onits way to the deltoid and to teres minor. The integrityof the musculocutaneous nerve should also bechecked clinically, including its motor innervation ofbiceps and the sensory supply to the medial forearm.It is usually not necessary to visualise the nerve atoperation but it must be borne in mind that it enters thebiceps approximately 5 to 8 cm below the tip ofcoracoid although this distance has been shown to bevery variable [15]. Vascular lesions are infrequentlyassociated with fractures of the proximal humerus [16].In the presence of a fracture an enlarging ecchymosisor a painful tense haematoma should alert the surgeonto underlying haemorrhage which is either venous or,more rarely, arterial. Ideally, angiographic assessmentshould be considered. If this is not possible surgicalexploration is mandatory.

Classification

The Neer classification [17] and the AO/ ASIFclassification [18] are the most widely used systems toevaluate and determine treatment of proximal humeralfractures. The Neer classification is based on thenumber of fracture parts (displacement >1 cm,angulation >45°), direction of dislocation, andinvolvement of the articular surface. The AO/ASIFclassification system for proximal humerus fracturesbroadly groups fractures based on the degree ofarticular involvement and likelihood of vascular injury.Observer reliability and reproducibility for both theNeer and the AO/ASIF classification is fair to poor; it isunlikely that one orthopaedic surgeon will assign thesame classification to a proximal humerus fracture attwo separate times, just as it is unlikely that twoorthopaedic surgeons will agree on a classification.Given these limitations, the AO/ASIF classification forthe three basic types of humerus fracture is moreuser-friendly.

Pre operative assessment

For a successful diagnosis of a fracture of the proximalhumerus it is imperative to have two viewsperpendicular to each other. The glenohumeral jointline should be completely open with no overlap of thehead upon the glenoid. The most common standardprojections are the true AP view of the glenohumeraljoint perpendicular to the plane of the scapula and theaxillary view parallel to this plane and perpendicular tothe acromion. The axillary view necessitates only afew degrees of abduction or, if the arm is held ininternal rotation by a bandage, a Velpeau view can bemade in which the patient leans backwards with thex-ray beam directed superoinferiorly from the top ofthe shoulder on to a cassette located at the patient’selbow. AP internal and external rotation views may behelpful but are difficult to obtain in cases of acuteinjury. Scapular Y views are sometimes of use but arenotoriously difficult to interpret and, unless perfectlyperformed, should not be used to exclude, for example,posterior fracture-dislocations [13]. CT is a usefuladjunct and three-dimensional reconstructions canshow features not readily recognisable on plain films[19, 20, 21 ]. MRI may accurately delineate suspectedsoft tissue injury. In case of doubt angiography shouldbe used to determine vascular integrity.

Management protocol:

Although the management of displaced proximalhumerus fractures has evolved toward humeral headpreservation, treatment should be guided by carefulassessment of vascular status, bone quality, fracturepattern, and degree of comminution, as well as patientfactors, such as age and activity level. Patients whoare either medically unstable or inactive are poorcandidates for surgery and instead may be treatedwith sling immobilization until the fracture heals. Theultimate goal is maximum shoulder function andminimal shoulder pain.The likelihood of humeral head osteonecrosis isimplicit in the AO/ASIF classification; thus, determiningthe AO/ASIF fracture type is the initial step indetermining the probability of humeral headpreservation. Type A is a unifocal, extra-articularfracture with an intact vascular supply. Type B is abifocal, extra-articular fracture with possible injury tothe vascular supply. Type C is an articular fractureinvolving the anatomic neck with a high likelihood ofosteonecrosis. Cortical thickness of the humeraldiaphysis is a more reliable and reproducible predictor



of both bone mineral density and the potential forsuccess of internal fixation than is age [22]. Afteradjusting for magnification, medial and lateral corticalthickness is measured from the anteroposterior view ofthe proximal humerus [22]. The first level, the mostproximal aspect of the humeral diaphysis, occurs atthe level in which the endosteal borders of the medialand lateral cortices are parallel. The second level is 20mm distal to the first level. The combined corticalthickness is the average of the medial and lateralcortical thickness at the two levels [22]. Nonsurgicaltreatment, suture fixation, and hemiarthroplasty maybe the best options for the patient with combinedcortical thicknessNonoperative treatment:Nonsurgical management traditionally has beenrecommended for nondisplaced and minimallydisplaced proximal humerus fractures. Slingimmobilization with or without closed reduction alsohas a role in the management of displaced proximalhumerus fractures.3 Court- Brown and colleagues [23,24] recommend 2 weeks of sling immobilizationfollowed by physical therapy for patients with two-partsurgical neck fractures [24] and valgus-impactedfractures [23]. Two-part proximal humerus fractureswith >66% translation were treated with either a slingor with internal fixation with flexible intramedullarynailing and tensionband wires [23, 24]. No statisticaldifference was reported between the groups in termsof Neer score, [17, 25] return to activities of daily living,and fracture union [23, 24]. The data demonstrate thatthe raw Constant score deteriorates with advancingage and degree of displacement. However, whencalculated based on age-adjusted Constant score, theolder patients actually had better scores than did theyounger patients [23, 24, 26, 27]. Therefore, slingimmobilization is an appropriate treatment option forpatients older than age 60 years with valgus-impacted,two-part surgical neck or two-part tuberosity fractures.Surgical approaches:Deltopectoral approach. In displaced fractures of theproximal humerus the most common surgicalapproach is the deltopectoral with the patient in the‘beach-chair’ or semi-sitting position.3,4 Generalanaesthesia is used and sometimes a scalene blockmay be performed before intubation. This allows forlighter anaesthesia and the absence of pain onawakening will prevent uncontrolled movement by thepatient and therefore protect the osteosynthesis. Anoblique incision 15 cm long is made starting frombelow the clavicle and passing over the coracoid. Afterappropriate haemostasis of the subcutaneous tissue,the deltopectoral interval and the cephalic vein areidentified. If there is difficulty in finding the interval

because of swelling the search should be made moreproximally near the clavicular insertion of the deltoidand pectoralis major muscles where, usually, theinterval widens. The cephalic vein is left either with thedeltoid muscle or with the pectoralis muscle. It may beligated. The conjoined tendons are then retracted anda curved blunt retractor is placed under the deltoidmuscle around the fragments of the humeral head inthe subacromial space after blood clot and bursaltissue have been removed. The axillary nerve isidentified and palpated by sliding the index fingerunder the conjoined tendons on to the anterior aspectof subscapularis. It is then important to locate thebiceps tendon and to use it as a landmark to help toidentify the fragments of the greater and lessertuberosities with their attached tendons. With two-partfractures involving the surgical neck, the alignment ofbiceps may reflect the adequacy of the reduction. In afracture in which the lesser tuberosity is not detachedbut where the surgeon wishes to inspect the articularsurface, a small incision through the interval can bemade and the articular surface observed. All thetendinous structures should then be identified withstay sutures. Reduction may be accomplished byvarious techniques from the use of plates and screwsin particularly strong bone to obtain a ‘rigid’ fixation, torelying on osteosutures or wires to obtain atension-band construct. This last technique may beparticularly indicated in the presence of osteoporosis.A control radiograph should always be obtained beforeclosure. In order to obtain a satisfactory view the x-raytube should be placed on the contralateral side of thepatient and the cassette applied to the body of thescapula. This will give a view perpendicular to theplane of the scapula allowing interpretation of thequality of the reduction and of the position of thetuberosities.Transdeltoid split approach. In cases of isolatedfractures of the tuberosity or if an intramedullarydevice is employed, it is sometimes sufficient to use atransdeltoid split approach. The patient is in asemi-sitting position and the skin incision may followthe direction of the muscle fibres along the upperdeltoid at the junction of the anterior and middle thirdsor as a vertical ‘sabre-cut’. The deltoid is split along itsfibres no more than 5 cm from the acromion in order toavoid injury to the axillary nerve. The cuff is thenidentified and the haemorrhagic subacromial bursapartially removed. The fragments of the fracture arethen identified and reduced. Fixation may be bymeans of isolated screws, wiring or heavy sutures. Ifproximal intramedullary nailing is chosen the sameapproach can be used. The tendon of supraspinatus issplit to allow the introduction of the nail into the



tuberosity. The proximal part should be buried underthe level of the articular cartilage. Imageintensifiercontrol is essential to ensure a satisfactory outcome.Operative treatmentDespite general agreement that displaced or morecomplex fractures should be treated operatively, thereis no consensus on the type of surgical fixation thatshould be used. Various methods, such as closedreduction and percutaneous pinning (CRPP), tensionband wiring, intramedullary nailing, plate fixation, andhemiarthroplasty have all demonstrated mixed results.Fracture pattern, fracture displacement, bone quality,preexisting rotator cuff disease or arthrosis, andpatient function are important factors to consider indeveloping a treatment plan. The primary goal shouldbe a construct sufficiently stable to begin early rangeof motion of the shoulder [28-34].Displaced 2-part and some 3-part proximal humerusfractures may be managed with CRPP in selectedcases. Alternatively, intramedullary nails (IM) designedspecifically for proximal humerus fixation may beadvantageous in some of these fractures. Openreduction and internal fixation (ORIF) has also beenwidely used in 2-part, 3-part, and 4-part fractures.Valgus-impacted 4-part fractures are less likely tohave disruption to the humeral head blood supply anddevelop osteonecrosis; thus, ORIF is generallyrecommended for these injuries [35-39]. In contrast,displaced 3-part and 4-part fractures are associatedwith higher rates of osteonecrosis and othercomplications [25, 26, 35, 40-42]. Open reduction andinternal fixation is advocated for patients who areyoung and active, but patients who are elderly may bebetter treated with hemiarthroplasty, depending ontheir bone quality and physiologic age [43-46]. Recentadvances in internal fixation, with locked plate-screwconstructs, have extended our ability to retain thehumeral head in some of these patients [47]. Theresults and outcomes of internal fixation versushemiarthroplasty in this group of patients have notbeen compared. The following discussion will reviewvarious surgical treatment options.Percutaneous PinsFirst described by Jaberg, this technique is demanding,but it can be very effective for unstable 2-part surgicalneck fractures and even some 3-part or 4-partfractures in patients with good bone quality [48-50].Closed reduction, with or without percutaneousassistance, is performed, and 2.5-mm terminallythreaded Schanz pins are used to stabilize the fracture.Knowledge of the anatomy of the axillary andmusculocutaneous nerves is essential in avoidinginjury to these structures [42, 51, 52].Pins should beplaced in a divergent fashion to optimize stability.

Three to 4 pins are directed proximally across thesurgical neck fracture, and 1 or 2 pins are placedthrough the greater tuberosity into the medial cortex.These augment the fixation of the surgical neckfracture and will also stabilize a greater tuberosityfragment. Multiple, tangential fluoroscopic viewsshould be obtained to avoid penetration of the articularcartilage. Passive range of motion is initiatedpostoperatively. Pins placed through the greatertuberositywill limit abduction until they are removed after 3–4weeks. The other pins are removed after 6–8 weeks.Surgical trauma to the soft tissues and fracturefragments is minimized with percutaneous pinning.This results in less blood loss and scar tissue andbetter preservation of fracture biology compared withother techniques. One recent study reviewed 71patients treated with percutaneous pinning, versus acohort of patients matched for age and fracture patterntreated with ORIF. These authors noted that theincidence of osteonecrosis was higher after ORIF,potentially secondary to surgical trauma [50].Percutaneous pinning is a viable option, particularly inyoung patients with suitable bone quality. It isspeculated that earlier return of mobility and betterfinal range of motion may also be possible with thismethod. However, complications include pin infections,loss of reduction, and pin migration. Careful patientselection will minimize these problems. This method isbest suited to patients who have good bone qualityand who can comply with postoperative activityinstructions. It is not appropriate for anatomic neckfractures, fractures with humeral head comminution, orseverely impacted fractures with valgus angulation.Rather, it works well for 2-part fractures and for 3-partfractures with minimal greater tuberosity displacement.Jaberg reported 95% fracture union after 6–8 weekswith CRPP but had 4 cases (7%) of pin tract infection[48]. Fenichel et al retrospectively reviewed 50patients with unstable 2-part and 3-part proximalhumerus fractures treated with this method [53]. Theyhad no pin infections, osteonecrosis, or neurovascularproblems. However, 7 patients experienced a loss ofreduction, 3 of whom underwent revision fixation. Theyrecommended careful patient selection and closefollow-up in the first 4 weeks after surgery to minimizeloss of reduction and fixation. Better functionaloutcomes were noted in patients who did not have anassociated fracture of the greater tuberosity, which isconsistent with the experience of other authors [42, 48,49].Intramedullary NailsIntramedullary nails are effective in stabilizing someproximal humerus fractures [29, 54, 59]. Preservation



of blood supply through indirect reduction is anadvantage of this technique. A greater propensity formaintenance of reduction is likely in 2-part surgicalneck fractures as opposed to those with associatedfractures of the tuberosities. Several manufacturersoffer nails specifically designed for proximal humerusfractures, with multiplanar locking, blade fixation forthe proximal fragment, or both. These implants may beparticularly useful for proximal humerus fractures incombination with humeral shaft injuries [54, 56].Disadvantages include potential damage to the rotatorcuff and chronic shoulder pain.An anterior acromial approach is recommended forantegrade humeral nailing. This minimizes surgicaltrauma to the rotator cuff, versus a lateral acromialapproach, which can injure the insertions of teresminor and infraspinatus muscles. Care should betaken to protect the axillary nerve. Blunt dissection andvisualization to bone can protect the axillary nervefrom damage when proximal interlocking bolts aredirected from lateral to medial [60]. A lateral startingpoint or failure to achieve reduction of the proximalfragment will result in varus malalignment [56].Meticulous technique and understanding of theassociated anatomy and radiographic landmarks willprevent this problem. Displaced 2-part fractures aremost amenable to nailing. If 3-part fractures aretreated with this method, the greater tuberosity shouldbe reduced and provisionally stabilized with Kirschnerwires before the starting point for the nail is developed.Agel et al reported the results of 20 patients withproximal humerus fractures that were treated with aPolarus nail [55]. This implant has options for proximalinterlocking in several directions. Although only 11 of20 patients healed without any complications, thisimplant can be effective for certain fracture patterns.The authors cautioned against using a nail when thelateral metaphysis is comminuted or if the startingpoint extends into the greater tuberosity. In such casesfracture displacement, fixation failure, or both are morelikely [55, 61]. Similarly, Rajasekhar et al alsodemonstrated success with this implant, in both youngand elderly patients [57]. Their population of 30patients included primarily 2-part fractures and had80% satisfactory to excellent results. Otherintramedullary implants more recently developed foruse in proximal humerus fractures include proximalblade fixation or multiplanar locking options, some withthreaded screws to stabilize greater tuberosity andlesser tuberosity fragments [29, 56]. The early resultsof these implants appear promising, even in elderlypatients [29].Open Reduction and Internal Fixation:Open reduction and internal fixation is an effective

method of treatment for proximal humerus fractures. Itis frequently used for displaced 3-part and 4-partfractures and valgus-impacted 4-part humerusfractures to promote early motion of the shoulder [35,37, 38, 42, 62]. Multiple fixation options have beendescribed, ranging from tension band fixation [25, 33,63] to conventional large fragment and small fragmentplates and screws [38, 46, 64-70] to new locked plateand screw constructs [47, 71-81]. No comparativeclinical studies to date have been done to determineclear indications and limitations of these methods.Conventional Plates:A deltopectoral approach or deltoid-splitting approachmay be performed, depending on the fracture patternand surgeon experience [38, 39]. Care should betaken to preserve rotator cuff attachments and thehumeral head blood supply in all cases [39, 46, 50, 67,82-85]. Articular fractures should be anatomicallyreduced, and relationships of the tuberosities and theirassociated rotator cuff insertions should be restored.Shortening of the humerus, through impaction of acomminuted surgical neck fracture, may be desirable.This improves the stability of the construct byincreasing the surface area of bony contact andproviding an intact medial buttress [74]. Carefulattention to safe implant placement is essential. Platesshould not impinge on the acromion, the bicepstendon, or rotator cuff insertions. Screw trajectoriesshould be strategic and divergent to optimize purchasein the humeral head. Central and inferior placement,with some screws in the medial cortex, may bebeneficial [74, 86].The fixation should ideally be rigidenough to promote early rehabilitation.Initial reports of ORIF reviewed experiences with theAO large fragment T-plate [46, 66, 68, 87]. By Neer’scriteria, Kristiansen et al reported only 45%satisfactory results for 3-part fractures [66]. Fixationfailures and some of the poor results could beattributed to deficient bone quality in elderly patients.Placing the T-plate more inferiorly on the greatertuberosity avoids impingement on the acromion andincreases the number of good results, particularly in3-part fractures [48]. However, both of these earlystudies had high rates of intraarticular screwplacement. Precise attention to surgical technique toensure accuracy of screw placement will prevent thiscomplication. In a group of younger patients (20–40years old), 83% satisfactory results were obtained withcareful placement of a T-plate or semitubular bladeplate [87]. However, poor results were seen in patientswith underlying rotator cuff damage. In an attempt toreduce complications associated with the use of theT-plate, Esser advocated a cloverleaf plate [64]. Thisis a small fragment implant with more options for



proximal fixation. It can be modified by removing thearm on the end of the plate to reduce the potential forprominence on the humeral head. In 26 patients with amean age of 55 years who had 3-part and 4-partfractures, 92% good results were obtained with nononunions and no osteonecrosis [64]. Other authorshave reported success with this method [38, 42, 46,62] and by applying principles of indirect reduction andfixation with meticulous attention to the surroundingsoft tissues.Semitubular plates may be fashioned into a bladeplate for displaced 2-part and 3-part fractures. Thistechnique may provide improved fixation of thehumeral head, depending on the length of the bladeand the quality of the bone [88, 89]. Several reportshave described good results with few hardwarecomplications [69, 70, 87]. Similarly, 3.5- or 4.5-mmblade plates may be created by bending standardlimited contact dynamic compression plates. Theseare useful for treating acute fractures or nonunions[90-92]. More recently, 3.5- and 4.5-mm blade plateshave been developed by various manufacturers.Moderately good outcomes have been demonstrated,even in elderly patients [65, 93] as a result of morerigid fixation of the humeral head. This method iseffective for displaced 2-part fractures and can beused in 3-part fractures after reduction and fixation ofthe greater tuberosity. Some prefabricated bladeplates designed for the proximal humerus have acannulated system to facilitate accurate bladeplacement. Meier et al reviewed 42 consecutivepatients treated with a customized, cannulated,110-degree blade plate [67]. They described indirectreduction of the humeral head fragment andrestoration of the head neck angle, while minimizingimplant prominence and proximity of the plate withrespect to the acromion. This fixation was sufficientlystable to permit early rehabilitation. However, 8patients in their series (19%) had perforations of thehumeral head by the blade because the fracturescollapsed during the healing process. The authorsspeculated that the valgus angle of their implant,versus 90-degree blade plates in other reports,permitted protrusion of the blade. To prevent thiscomplicat ion, 90-degree blade plates arerecommended.Collectively, these reports suggest that open reductionto restore relationships of the shoulder joint, along withrigid internal fixation to initiate early range of motion,will optimize functionality [31, 62, 67]. It appears thatalignment is less important than achieving a stableconstruct to permit early range of motion of theshoulder [28, 32-34, 94]. No conclusive informationexists from randomized controlled trials comparing

ORIF with nonoperative management [32, 33, 95, 96].Furthermore, none of the clinical studies to date havecompared different types of fixation; thus, largerandomized trials are necessary to determine theoptimal type of treatment for various proximal humerusfractures.Locking Plates:Several new locked plate-screw devices have beendeveloped over the past few years. Researchsuggests plates with attached (locked) screws mayprovide improved fracture stability and healing. Whena screw is locked to the plate, a fixed point of contactis created, which may be advantageous in thecancellous bone of the proximal humerus, especially inelderly patients with osteoporosis [97-100].Locking plates specifically designed for the proximalhumerus have favorable shapes and screwconfigurations, which may enhance maintenance ofreduction and reduce hardware complications.Biomechanical data suggest some advantages tolocking plates [101, 102]. One early study of anexperimental precursor to locking plates reportedgreater stiffness and increased energy to failure whencompared with an AOT-plate [103]. In osteoporoticbone, torsional stiffness was improved when lockingplates were compared with cannulated 90-degreeblade plates in a cadaver surgical neck fracture model[100]. However, no difference was seen with bendingloads in the same model. Conflicting information hasbeen published regarding the performance ofintramedullary nails in the proximal humeruscompared with locking plates. In a surgical neck, gaposteotomy, cadaver model the nail has demonstratedsuperior stiffness with axial loading [104] as well astorsional and bending loads [104, 105]. However,Edwards et al found more stiffness in torsion andbending and less displacement of a locked proximalhumerus plate compared with a nail in a similar model[106]. They concluded that locking plates may beparticularly advantageous in osteoporotic bone.Some 3-part and 4-part fractures and head-splitfractures are not amenable to nailing, so the clinicalapplicability of such biomechanical information islimited. Individualized decision making is essentialwhen choosing among these implants in the clinicalsetting, with consideration to fracture pattern andunderlying patient factors including bone quality,rotator cuff pathology, or associated injuries. Earlyclinical results of locking proximal humerus plateshave been promising, although no comparisons withother techniques have been published [47, 71, 73,75-80]. Despite the paucity of literature to date andincreased implant costs, surgeons have begun to uselocked plating for both simple and complex proximal



humerus fractures based on the theoretical benefit ofimproved fracture stability [75, 77].As with other methods of ORIF, a deltopectoral ordeltoid-splitting approach may be used, depending onthe fracture pattern and surgeon experience [39, 107].It is important to reduce the fracture fragments prior tolocking screws to the plate. The plate may be used toaid the reduction. Nonlocked screws can compress theplate to the bone, and nonlocked screws may also beused to achieve interfragmentary compression. Thisshould be done prior to placing locked screws. Thelocked screws will then serve to protect the reduction[102]. Care should be taken to maintain theappropriate angle when seating screws into the plate.This will prevent cross-threading and may minimizescrew disengagement from the plate over time [72, 73,76, 108]. The presence of medial column support willimprove the stability of the construct and minimizeearly loss of reduction [74]. Gardner et al definedmedial column support as an anatomic or slightlyimpacted reduction, along with a superior directedoblique locked screw in the inferomedial region of theproximal fragment [74].The largest series of locked plating in the proximalhumerus was recently reported by Kettler et al [76].These authors reviewed 176 patients treated with thePHILOS plate. Technical errors included 11% withscrew perforations into the glenohumeral joint. Another11% had secondary displacement of the implant fromthe humeral head or shaft, and 14% had malunions[76]. Strict attention to fracture alignment and implantplacement may prevent some of these complications.Bjorkenheim et al [71] described 72 patients with amean age of 67 years with isolated proximal humerusfractures treated with the LCP proximal humerus plate.Half achieved a good or excellent constant score after1 year follow-up. Elderly patients and those withC-type fractures (displaced articular and/or anatomicneck fractures) [108] had worse functional scores.Only 3 cases of osteonecrosis and 2 nonunions wereidentified, but 19 fractures (26%) settled into varusposition. Initial varus malreduction has been noted toincrease the risk of fracture fixation failure [71].Fankhauser et al noted loss of proximal screw fixationand varus malalignment in 3 of their 29 patientstreated with locked plating [73]. They recommendedaugmenting the proximal fixation with sutures placedthrough the rotator cuff and attached to the LCP plate.They also had 2 patients with osteonecrosis and 1 withplate failure. Constant scores averaged 75 for allpatients, and worse scores noted were againassociated with C-type fractures.Other recent reports have focused on limiting surgicaltrauma while reducing and stabilizing the proximal

humerus fracture with a locking plate. A minimallyinvasive deltoid splitting technique can be usedwithout damage to the axillary nerve if screws arelimited to superior and inferior holes [109]. Gallo et aladvocate 2 incisions with a delto pectoral exposure forthe shaft and head and a lateral approach to thegreater tuberosity [107]. The plate can then bedirected through the lateral wound and used tostabilize the fracture. Surgical trauma to the deltoid isminimized, and maintenance of the reduction andaccurate implant placement may be facilitated with thismethod. It may be particularly effective in patients whoare obese or those with large shoulder muscle mass.Irrespective of the type of plate used, meticuloussurgical technique will maintain the biology around thefracture to promote healing and diminish theoccurrence of osteonecrosis. This will also minimizescar tissue and soft-tissue damage, which can impairmobility and function.Early rehabilitation and restoration of functionalmobility of the shoulder is the key to success afternonoperative management of these injuries [28-33, 94].Similarly, the success of surgical treatment dependson maintaining the reduction to promote earlyrehabilitation [31, 33, 110]. Perhaps the best indicationfor surgical treatment is to maintain an adequate,stable fracture reduction to initiate early range ofmotion. It is possible that locking plates used forunstable proximal humerus fractures permit moreaggressive postoperative rehabilitation and therebyfacilitate more rapid return to productive function. Itappears that the benefit of locked plating is in thosecases where adequate fixation via other methods isnot possible. Locking technology is not necessary formany types of proximal humerus fractures, and its usegenerates substantial implant expense. The specificindications, limitations, and cost effectiveness of thelocked plating in the proximal humerus warrant furtherstudy.Hemiarthroplasty:Hemiarthroplasty remains a useful option for olderpatients with anatomic neck and head-split fractures[36, 44, 45, 110-117] It is controversial whether to treatfunctional elderly patients with 3-part and 4-partfractures with hemiarthroplasty versus ORIF [47, 118].Displaced 4-part fractures are associated withosteonecrosis in 21% to 75% of cases, compared to8% to 26% of valgus-impacted 4-part fractures [40-42,46, 102]. This has been 1 argument favoringhemiarthroplasty in elderly patients with displacedcomminuted proximal humerus fractures. However, insome cases the presence of osteonecrosis may not bepainful. It is interesting that osteonecrosis may bepresent in only a portion of the humeral head and may



not result in collapse in all patients [46, 53, 67, 83, 85].Thus, the age of the patient, the quality of the bone,the fracture pattern, and amount of comminution areall important considerations in developing a treatmentplan. The advent of locking plates has improved ourability to stabilize some fractures and has likelyreduced the frequency of hemiarthroplasty in the acutesetting for proximal humerus fractures. In some casesit may be impossible to achieve adequate stability witha plate and screws, and a decision to performhemiarthroplasty is made intraoperatively [46, 75]. It isprudent to prepare for this ahead of time and todiscuss both options with patients. It is unknownwhether patients function better over time after ORIFversus hemiarthroplasty. However, early treatment ofdisplaced fractures, versus delayed hemiarthroplasty,results in fewer complications and better functionalresults [45, 119-121]. This is likely the result ofextensive scar tissue, distortion of the anatomy, andchronic disuse of the shoulder when these fracturesare treated with late arthroplasty.A recent analysis of literature to date on 4-partproximal humerus fractures concluded that insufficientevidence exists to define the optimal treatment forthese injuries [95]. Little comparative information alsoexists when determining the outcomes of ORIF versushemiarthroplasty. Only 1 randomized controlled trialhas been undertaken to date. Tension band wiringwas compared to hemiarthroplasty in a total of 30elderly patients [122]. A potential 91% reduction in riskof reoperation was seen with hemiarthroplasty.Extrapolation of these findings to a younger populationcannot be done. Furthermore, no comparativeinformation exists regarding the complications andfunctionality of hemiarthroplasty compared with moremodern methods of internal fixation, includingstandard plates and screws or locking plates. Becausecurrent literature is insufficient to promote clinicaldecision-making, larger trials and randomized studiesare needed [95, 96].Patients who undergo hemiarthroplasty acutely forproximal humerus fractures frequently experience lossof function, with residual stiffness and weaknesscompared with the contralateral shoulder, [103]although pain relief may be satisfactory [43, 45, 110,112-117]. This is likely magnified by the fact that alarge portion of this patient population could be moreactive and functional at baseline than patients whoreceive shoulder arthroplasty for degenerative arthritis.On the other end of the spectrum, elderly patients whosustain proximal humerus fractures in falls may beless functional overall, thus less capable ofparticipating in aggressive rehabilitation, leading topoor functional results after hemiarthropalsty [110, 112,

119, 123, 124].Technical considerations when performinghemiarthroplasty include component position andtuberosity reconstruction [125, 126]. These issues areproblematic when faced with metaphysealcomminution or bone loss and either very large orcomminuted greater tuberosity fragments. Prosthesesspecifically designed for fracture treatment canaddress these concerns. These have multiple optionsfor suture attachment and can accommodate a largegreater tuberosity fragment without causingimpingement. Application of autogenous bone graftfrom the humeral head to the area between thegreater and lesser tuberosities may improve healing ofthe tuberosities. Care should be taken to keep cementout of this region because it would interfere with bonehealing.One recent study reviewed 71 patients treated acutelywith hemiarthroplasty for proximal humerus fractures[125]. Their mean age was 66 years, and indicationsfor surgery included displaced 4-part and 3-partfractures, head-split fractures, and anatomic neckfractures. Of the patients, 93% reported no or slightpain and were satisfied. Malreduction of the greatertuberosity was the most common complication,occurring in 22% of cases. Overall, patient functionwas most affected by the quality of the reconstructionof the greater tuberosity [125]. This is consistent withother studies [43, 110, 116, 124, 127, 128]. Additionalpatient factors that contribute to successful outcomeinclude younger age, strong functional status atbaseline, and no associated neurologic deficits [43].Careful attention to component position and tuberosityreconstruct ion during surgery wi l l reducecomplications [126]. By coupling this with anappropriately aggressive rehabilitation plan, patientsatisfaction and function will be maximized [43, 45,111, 125, 127].

Summary

Proximal humerus fracture management is constantlyevolving, part icular ly in l ight of improvedunderstanding of proximal humerus fracturecharacteristics and innovations in surgical techniqueand technology. The orthopaedic surgeon shouldapproach proximal humerus fractures on acase-by-case basis and tailor treatment according topatient and fracture characteristics. Treatmentdecision-making should include assessing thevascular status of the humeral head, determining theoptimal fixation constructs, and implementing localadjuvants as needed to enhance anatomic fracture



healing. The likelihood of humeral head ischemia isestablished using the AO/ASIF classification andHertel’s radiographic criteria. Fractures with AO/ASIFtype C pattern, metaphyseal extension2 mm areassociated with high probability of osteonecrosis andprobably are best treated with hemiarthroplasty. Whenfixation is required, fracture pattern and corticalthickness should guide the treatment approach andfixation technique. AO/ASIF type A fractures aretypically treated with sling immobilization. Proximalhumerus fractures with surgical neck translation >66%or tuberosity displacement >5mmmay be treated withtransosseous suture fixation (cortex4 mm). Formultifragment fractures, locked compression platingcreates a stable construct with preservation of theperiosteal blood supply. Calcium phosphate cement,demineralized bone matrix, and allografts areimportant local adjuvants that may improve rates ofosseous union and minimize malunion. So, humeralhead preservation and osteosynthesis are beingincreasingly favoured.

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Management Of Displaced Proximal Humeral Fractures

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